[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Infectious Diseases
    January 10, 2020

    Association Between Environmental Factors and Toxigenic Clostridioides difficile Carriage at Hospital Admission

    Author Affiliations
    • 1Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
    • 2Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
    • 3Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
    • 4Department of Pathology, Medical College of Wisconsin, Milwaukee
    • 5Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
    JAMA Netw Open. 2020;3(1):e1919132. doi:10.1001/jamanetworkopen.2019.19132
    Key Points español 中文 (chinese)

    Question  Is an individual’s location of residence associated with asymptomatic carriage of toxigenic Clostridiodes difficile?

    Findings  In this cohort study of 3043 adult participants admitted to the hospital, patients who lived closer to livestock farms had a higher likelihood of carrying toxigenic C difficile at the time of hospital admission.

    Meaning  Clostridioides difficile is acquired not only in hospitals but also in the community setting. Livestock farms may expose people to higher loads of C difficile via runoff water and to substances that disrupt the intestinal microbiome, placing them at higher risk of C difficile colonization.


    Importance  Clostridioides difficile infection is the most frequent health care–associated infection in the United States. However, exposure to this organism might occur outside the health care setting.

    Objective  To examine whether exposure to environmental factors, such as livestock farms, is associated with a higher probability of being colonized with C difficile at hospital admission.

    Design, Setting, and Participants  This retrospective cohort study was conducted from May 1, 2017, to June 30, 2018, at a teaching-affiliated hospital in Milwaukee, Wisconsin. All consecutive patients underwent C difficile screening using a nucleic acid amplification test at hospital admission. Data analyses were performed from July 2018 to October 2019.

    Exposures  The distances from patient residence to the nearest livestock farms, meat processing plants, raw materials services, and sewage facilities were measured in addition to risk factors previously evaluated in other studies.

    Main Outcomes and Measures  The main outcome was a positive result on C difficile screening tests performed within 72 hours of hospital admission.

    Results  A total of 3043 patients admitted to the hospital were included in the final analysis. Of those, 1564 (51.4%) were women and 2074 (68.9%) were white, with a mean (SD) age of 62.0 (15.9) years; 978 patients (32.1%) were admitted to hematology-oncology units. At first admission, 318 patients (10.4%) were detected through testing as C difficile carriers. Multivariable logistic regression analyses were performed on a stratified sample of patients based on hematology-oncology admission status. These analyses indicated that although patients admitted to hematology-oncology units were 35% more likely to be colonized with C difficile, no significant association existed between their sociodemographic and economic characteristics or health care and environmental exposures and the likelihood of a positive C difficile test result. In contrast, among patients admitted to non–hematology-oncology units, comorbidities increased the likelihood for colonization by more than 4 times; women had 60% greater colonization than men, and a history of recent hospitalization (ie, within the preceding 6 months) increased the likelihood of colonization by 70%. Residential proximity to livestock farms were all significantly associated with a higher likelihood of a positive C difficile test result. Residential proximity to livestock farms more than doubled the probability of C difficile colonization in patients admitted to non–hematology-oncology units.

    Conclusions and Relevance  A shorter distance between residence and livestock farms was associated with C difficile colonization. Knowledge of the epidemiology of C difficile in the community surrounding the hospital is important, as it has potential implications for the incidence of hospital-onset C difficile infection.